Comparison of epidural analgesia with ultrasound-guided bilateral erector spinae plane block in aorto-femoral arterial bypass surgery.

OBJECTIVE: Thoracic Epidural Analgesia (TEA) was compared with ultrasound-guided bilateral erector spinae plane (ESP) block in aorto-femoral arterial bypass surgery for analgesic efficacy, hemodynamic effects, and pulmonary rehabilitation. DESIGN: Prospective randomized. SETTING: Tertiary care centre. PARTICIPANTS: Adult patients, who were scheduled for elective aorto-femoral arterial bypass surgery. INTERVENTIONS: It was a prospective pilot study enrolling 20 adult patients who were randomized to group A (ESP block = 10) and group B (TEA = 10). Monitoring of heart rate (HR) and mean arterial pressure (MAP) and pain assessment at rest and deep breathing using visual analog scale (VAS) were done till 48-h post-extubation. Rescue analgesic requirement, Incentive spirometry, oxygenation, duration of ventilation and stay in Intensive Care Unit (ICU) were reported as outcome measures. Statistical analysis was performed using unpaired Student T-test or Mann-Whitney U test. A value of P < 0.05 was considered significant. RESULTS: HR was lower in group B than group A at 1 and 2 h post- surgery and at 0.5, 16, 20, and 32 h post-extubation (P < 0.05). MAP were lower in group B than A at 60, 90, 120, 150, 180, 210, 240, 270 minutes and at 0 hour post-surgery and at 4 hours, every 4 hours till 32 hours post-extubation (P < 0.05). Intraoperative midazolam and fentanyl consumption, ventilatory hours, VAS at rest, incentive spirometry, oxygenation, and ICU stay were comparable between the two groups. VAS during deep breathing was more in group A than B at 0.5, 4 hours and every 4 hours till 44 hours post-extubation. The time to receive the first rescue analgesia was shorter in group A than B (P < 0.05). CONCLUSION: Both ESP block and TEA provided comparable analgesia at rest. Further studies with larger sample size are required to evaluate whether ESP block could be an alternative to TEA in aorto-femoral arterial bypass surgery.

Is airway pressure release ventilation, a better primary mode of post-operative ventilation for adult patients undergoing open heart surgery? A prospective randomised study.

Context: Cardiopulmonary bypass (CPB) induced acute lung injury is accounted for most of the post-operative pulmonary dysfunction which leads to decreased compliance and hypoxemia. Airway Pressure Release Ventilation (APRV) as compared to other modes of ventilation has shown to improve gas exchange in Acute lung injury (ALI)/Acute respiratory distress syndrome (ARDS) lungs. Aims: We hypothesized APRV as a better primary mode of postoperative ventilation in adult post-cardiac surgery patients. Methodology: The study included 90 postoperative surgical patients, which were randomized into three groups: SIMV-PC(P), APRV(A), and SIMV-VC(V) with 30 patients in each group. Subjects and Methods: Lung compliance and serial arterial blood gas were assessed at regular intervals. PaO2/FiO2 ratio (a measure of oxygenation) and lung compliance were used as an indirect indicator for improvement in lung function. Hemodynamic parameters were closely observed for all the patients. Statistical Analysis Used: Statistical analysis was done using 'R' software. Results: There was a statistically significant improvement in PaO2/FiO2 ratio in the APRV group as compared to other groups. There was also an improvement in lung compliance after 6 h of ventilation and lesser duration of ventilation in the APRV group. However, it was not statistically significant. Conclusions: Our study suggests that APRV can be a useful alternative primary mode of ventilation to improve lung compliance and oxygenation in adult post-cardiac surgical patients.

A prospective study on use of thrive (transnasal humidified rapid insufflation ventilatory exchange) versus conventional nasal oxygenation following extubation of adult cardiac surgical patients.

Background: Postoperative pulmonary complications in cardiac surgery increase mortality and morbidity. High flow nasal cannula oxygen therapy (HFNC) is one of the preventive measures to reduce the incidence of lung complications. HFNC can decrease dyspnea and improve physiologic parameters after extubation, including respiratory rate and heart rate, compared with conventional oxygen therapy. In this study, we evaluated the role of THRIVE (Transnasal Humidified Rapid Insufflation Ventilatory Exchange) after extubation. Methodology: We prospectively randomized 60 adults aged between 18 and 65 years undergoing elective cardiac surgery to either High flow oxygen therapy using THRIVE (Group A) or conventional nasal cannula (group B). Arterial paO2, paCO2, pH at three points of time i.e., 1, 2, 4 hrs after extubation were evaluated using arterial blood gas analysis. Ventilation duration, the incidence of reintubation, sedation score, mortality, and other complications were also assessed. Results: Thirty adults in each group had comparable patient characteristics. There was a statistically significant decline in paCO2 in group A at 1, 2, 4 hrs post extubation (P = 0.022, 0.02, <0.001) with a significant increase in oxygenation (P < 0.001) when compared to group B.ICU stay duration was similar between two groups. No complications were noted in both groups. Conclusion: THRIVE is safe to use following extubation in adult cardiac surgical patients.

Decrease in Anti-HBs Antibodies over Time in Medical Students and Healthcare Workers after Hepatitis B Vaccination.

BACKGROUND: Hepatitis B is one of the most important occupational hazards among healthcare workers (HCWs). This study aimed to measure the anti-HBs titres among the medical students and HCWs vaccinated against hepatitis B virus and to determine the association between anti-HBs levels and time since vaccination. MATERIALS AND METHODS: In this cross-sectional study, medical students and healthcare workers who had received all three doses of hepatitis B vaccination and completed at least six months after vaccination since the last dose were included. 3 ml blood was collected from subjects (n = 340) and anti-HBs titre was estimated using ELISA. RESULTS: A total of 340/400 subjects were aged between 18 and 60 years; 204 were females and 136 males. The median and interquartile range for time since vaccination were 5 and 5 years, respectively. Duration since vaccination was ≤5 years in 223 (65.5%), 6-10 years in 84 (24.7%), and >10 years in 33 (9.70%); among them, antibody titres were >10 mIU/ml in 94.1%, 79.7%, and 72.7% subjects, respectively. There was significant decline in antibody titres as duration of postvaccination increased. CONCLUSION: The proportion of subjects who were unprotected after 5 and 10 years after vaccination were 20% and 27%, respectively. The need for a booster dose can be made mandatory at least for healthcare professionals.

Evaluation of adjusted central venous blood gases versus arterial blood gases of patients in post-operative paediatric cardiac surgical intensive care unit.

BACKGROUND AND AIMS: Central venous catheters are in situ in most of the intensive care unit (ICU) patients, which may be an alternative for determining acid-base status and can reduce complications from prolonged arterial cannulation. The aim of this study was to examine the reliability between adjusted central venous blood gas (aVBG) and arterial blood gas (ABG) samples for pH, partial pressure of carbon-di-oxide (pCO2), bicarbonate (HCO3 (-)), base excess (BE) and lactates in paediatric cardiac surgical ICU. METHODS: We applied blood gas adjustment rule, that is aVBG pH = venous blood gas (VBG) pH +0.05, aVBG CO2 = VBG pCO2 - 5 mm Hg from the prior studies. In this study, we validated this relationship with simultaneous arterial and central venous blood obtained from 30 patients with four blood sample pairs each in paediatric cardiac surgical ICU patients. RESULTS: There was a strong correlation (R i.e., Pearson's correlation) between ABG and aVBG for pH = 0.9544, pCO2 = 0.8738, lactate = 0.9741, HCO3 (-) = 0.9650 and BE = 0.9778. Intraclass correlation co-efficients (ICCs) for agreement improved after applying the adjustment rule to venous pH (0.7505 to 0.9454) and pCO2 (0.4354 to 0.741). Bland Altman showed bias (and limits of agreement) for pH: 0.008 (-0.04 to + 0.057), pCO2: -3.52 (-9.68 to +2.65), lactate: -0.10 (-0.51 to +0.30), HCO3 (-): -2.3 (-5.11 to +0.50) and BE: -0.80 (-3.09 to +1.49). CONCLUSION: ABG and aVBG samples showed strong correlation, acceptable mean differences and improved agreement (high ICC) after adjusting the VBG. Hence, it can be promising to use trend values of VBG instead of ABG in conjunction with a correction factor under stable haemodynamic conditions.

Transesophageal echocardiography estimation of coronary sinus blood flow for the adequacy of revascularization in patients undergoing off-pump coronary artery bypass graft.

AIMS AND OBJECTIVES: Physiologically coronary sinus (CS) drains the left coronary artery (LCA) territory. Stenosis of the branches of LCA may decrease the coronary sinus blood flow (CSBF). Any intervention that aims at restoring the flow of the stenosed vessel increases coronary artery flow that should consequently increase the CSBF. Hence, this study was undertaken to assess the CSBF before and after each branch of LCA to determine the adequacy of surgical revascularization in patients undergoing elective off pump coronary artery bypass grafting (OPCAB) using transesophageal echocardiography (TEE). MATERIALS AND METHODS: Thirty consecutive patients scheduled for elective OPCAB were enrolled. CSBF was assessed before and after each branch of LCA revascularization using TEE. Left internal mammary artery (LIMA) Doppler was also obtained post LIMA to left anterior descending (LAD) grafting. RESULTS: Hemodynamic and echocardiographic variables were compared by means of Student's t-test for paired data before and after revascularization. The CSBF per beat (1.28 ± 0.71), CSBF per minute (92.59 ± 59.32) and total velocity time integral (VTI) (8.93 ± 4.29) before LAD grafting showed statistically significant increase to CSBF per beat (1.70 ± 0.89), CSBF per minute (130.72 ± 74.22) and total VTI (11.96 ± 5.68) after LAD revascularization. The CSBF per beat (1.67 ± 1.03), CSBF per minute (131.91 ± 86.59) and total VTI (11.00 ± 5.53) before obtuse marginal (OM) grafting showed statistically significant increase to CSBF per beat (1.91 ± 1.03), CSBF per min (155.20 ± 88.70) and total VTI (12.09 ± 5.43) after OM revascularization. In 9 patients, color flow Doppler of LIMA could be demonstrated which showed diastolic predominant blood flow after LIMA to LAD grafting. CONCLUSION: Demonstration of CSBF was simple and monitoring the trend of CSBF values before and after each graft of LCA territory will guide to determine the adequacy of surgical revascularization.

Evaluation of continuous non-invasive arterial pressure monitoring during induction of general anaesthesia in patients undergoing cardiac surgery.

BACKGROUND AND AIMS: Continuous arterial pressure monitoring is essential in cardiac surgical patients during induction of general anaesthesia (GA). Continuous non-invasive arterial pressure (CNAP) monitoring is fast gaining importance due to complications associated with the invasive arterial monitoring. Recently, a new continuous non-invasive arterial pressure device (CNAP™) has been validated perioperatively in non-cardiac surgeries. The aim of our study is to compare and assess the performance of CNAP during GA with invasive arterial pressure (IAP) in patients undergoing cardiac surgeries. METHODS: Sixty patients undergoing cardiac surgery were included. Systolic, diastolic, and mean arterial pressure (MAP) data were recorded every minute for 20 min simultaneously for both IAP and CNAP™. Statistical analysis was performed using mountain plot and Bland Altman plots for assessing limits of agreement and bias (accuracy) calculation. Totally 1200 pairs of data were analysed. RESULTS: The CNAP™ systolic, diastolic and MAP bias was 5.98 mm Hg, -3.72 mm Hg, and - 0.02 mm Hg respectively. Percentage within limits of agreement was 96.0%, 95.2% and 95.7% for systolic, diastolic and MAP. The mountain plot showed similar results as the Bland Altman plots. CONCLUSION: We conclude CNAP™ provides real-time estimates of arterial pressure comparable to IAP during induction of GA for cardiac surgery. We recommend CNAP can be used as an alternative to IAP in situations such as cardiac patients coming for non-cardiac surgeries, cardiac catheterization procedures, positive Allen's test, inability to cannulate radial artery and vascular diseases, where continuous blood pressure monitoring is required.

Maternal and congenital syphilis in Karnataka, India.

Screening women for syphilis during pregnancy and providing proper treatment are the cornerstones of congenital syphilis prevention. During 2008-2011, 6,221 pregnant women were screened for syphilis using the Rapid Plasma Reagin (RPR) and Treponema Pallidum Hemagglutination (TPHA) tests at R.L. Jalappa Hospital, Kolar, Karnataka, India. The seroprevalence of syphilis during pregnancy ranged from 0.57% to 0.78% during the study. Of the 35 women with a positive test, 26 (74.28%) were detected at the time of labor and 9 (25.71%) were detected during antenatal care. None of the women detected at the time of labor received penicillin therapy for syphilis. Adverse fetal outcomes due to untreated syphilis during pregnancy were seen in many of the cases. During the study 26 infants (3.69/1,000) were diagnosed with congenital syphilis. Our findings show detection and treatment of syphilis during pregnancy needs to be strengthened in the study area to reduce the incidence of congenital syphilis.

Pancreatic endocrine neoplasms: a current update on genetics and imaging.

Pancreatic endocrine neoplasms are rare pancreatic tumours that may occur sporadically or as part of inherited syndromes such as multiple endocrine neoplasia-1 syndrome, von Recklinghausen disease, von Hippel-Lindau syndrome and tuberous sclerosis complex. Recent advances in the genetics and pathology of hereditary syndromes have provided valuable insights into the pathophysiology and biology of sporadic pancreatic endocrine neoplasms. Evolving molecular data on the biology of these neoplasms have the potential for diagnostic, therapeutic and prognostic use.

Miscellaneous tumour-like lesions of the ovary: cross-sectional imaging review.

Miscellaneous tumour-like ovarian lesions are histobiologically diverse, and are often mistaken for the more common ovarian cancers, leading to aggressive management. Knowledge of characteristic clinical, laboratory and imaging findings of these select non-neoplastic ovarian entities allows correct diagnoses and permits optimal management.

Comparative study between dexmedetomidine and fentanyl for sedation during mechanical ventilation in post-operative paediatric cardiac surgical patients.

AIMS AND OBJECTIVES: To compare the efficacy of sedation and time taken for extubation using dexmedetomidine and fentanyl sedation in post-operative paediatric cardiac surgical patients. METHODS: A prospective randomized double-blind study involving 60 children undergoing open heart surgery was conducted. The patients were divided into two groups, each involving 30 patients. One group received fentanyl at 1 µg/kg/h (Group A) and the other received dexmedetomidine at 0.5 µg/kg/h (Group B) for post-operative sedation with intermittent rescue fentanyl 0.5 µg/kg bolus in either group as per requirement during suctioning. The efficacy of sedation was assessed using the Ramsay sedation score, paediatric intensive care unit sedation score and the tracheal suction score. The time taken for extubation from the stoppage of infusion was noted. RESULTS: Haemodynamic parameters between the two groups were comparable. All sedation scores were comparable in the fentanyl and dexmedetomidine groups. Average time (in minutes) required for extubation was 131.0 (±51.06 SD) in the dexmedetomidine group compared with 373.0 (±121.4 SD) in the fentanyl group. The difference in mean time for extubation was statistically significant. CONCLUSIONS: Dexmedetomidine facilitates adequate sedation for mechanical ventilation and also early extubation as compared with fentanyl.

Polyserositis due to Salmonellaenterica serovar Enteritidis.

Salmonella enterica serovar Enteritidis (S. Enteritidis), a non-typhoid Salmonella, is an important emerging pathogen that usually causes gastroenteritis. Here, we report polyserositis with right-sided pleural effusion and loculated collection of fluid in the peritoneum caused by S. Enteritidis in a 60-year-old man from southern India. The patient was immunocompetent and did not have preceding gastroenteritis or any local structural abnormality. Malnutrition and old age might have been the predisposing factors. The patient received intravenous ceftriaxone for 2 weeks followed by oral ciprofloxacin. Pleurocentesis and abdominal paracentesis were also done. The patient was cured as evidenced by clinical improvement and radiological disappearance of the fluid collection.

Killing of enteric bacteria in drinking water by a copper device for use in the home: laboratory evidence.

Water inoculated with 500-1000 colony forming units/ml of Escherichia coli, Salmonella Typhi and Vibrio cholerae was stored overnight at room temperature in copper pots or in glass bottles containing a copper coil devised by us. The organisms were no longer recoverable when cultured on conventional media, by contrast with water stored in control glass bottles under similar conditions. The amount of copper leached into the water after overnight storage in a copper pot or a glass bottle with a copper device was less than 475 parts per billion, which is well within the safety limits prescribed by the WHO. The device is inexpensive, reusable, easy to maintain, durable, does not need energy to run and appears to be safe. It has the potential to be used as a household water purification method for removing enteric bacteria, especially in developing countries.

Soft tissue infections with Arcanobacterium haemolyticum: report of three cases.

We report here three polymicrobial wound infections associated with Arcanobacterium haemolyticum in rural patients aged between 60-65 years. In two patients, one with cellulitis and the other with postoperative wound infection following amputation of the limb, Arcanobacterium haemolyticum was isolated repeatedly along with beta haemolytic streptococci (BHS). The BHS belonged to Lancefield's group G and group C respectively. In another patient, who was a diabetic with chronic osteomyelitis, Arcanobacterium haemolyticum was isolated along with Proteus vulgaris . All the three isolates of Arcanobacterium haemolyticum isolated by us were uniformly resistant to cotrimoxazole and sensitive to penicillin, erythromycin, clindamycin, ciprofloxacin and gentamicin. Erythromycin alone or combined therapy of penicillin with erythromycin or penicillin with ciprofloxacin was effective in treating these infections.

Control of blinding eye diseases in leprosy: strategies for India.

Over half of the people affected by leprosy worldwide are in India, many of whom are severely disabled when they present for care. Changes in policy and the integration of the leprosy programme with general health services has given rise to new challenges for the control of blinding eye disease in leprosy patients. This paper looks at the challenges posed: management, materials, manpower, money, and mobility--all of which are common barriers to the availability, access, and utilization of services--and to monitoring existing programmes. We consider strategies to overcome these challenges and fulfill the goal of VISION 2020--eliminating avoidable blindness--through the provision of comprehensive eye care and strengthening the existing infrastructure. Formal cooperation between national governments, non-governmental organisations, and International Development Agencies will need to continue, although possibly, in different roles and with plans modified to be relevant to the local needs of leprosy patients.